GP Referral Form

For Dr referrals please complete the form below. Otherwise Click Here to DOWNLOAD the GP Referral Form to complete and send a scanned copy through to our email info@salisburydaysurgery.com.au or FAX to (07) 3277 6226.

Date of Referral:*

Name of Patient:*

DOB:

Pregnancy Test: Positive Negative 

Gestation –Abdo: Ultrasound Scan:

G: P: M: T:

Doctor's Details:*

Address:*

Doctor's Provider Number:*

Contact No:*

Doctor's Email:*

Allergies:

Medications:

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Fasting Instructions

Appointments before 11.00.am:

  • Nothing to eat or drink after midnight (small sip of water up to 4 hours before the procedure)
  • No smoking, lollies or chewing gum.

Appointments after 11.00am:

  • Have a light breakfast of tea & toast up to 6.00am (no milk with tea or coffee).  After 6.00am nil by mouth (nothing to eat or drink).
  • No smoking, lollies or chewing gum.

What to bring to the appointment:

  • Bring in a spare pair of underwear, sanitary pads & a pair of socks
  • Don’t wear any nail polish, jewellery or make-up
  • Bring in your ID, Medicare card, Pension, Concession or Health Card Card
  • Any relevant scans, referrals or blood group records
  • Patient must have someone over the age of 18 to sign the discharge form and accompany them home
  • Must have someone stay with them for 12 hours after the procedure
  • Unable to drive, or sign legal documents for 24 hours